GW1--05501_Well Construction - GW1_20230825

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only: . I 1 —
i
1.Well Contractor Information: I
Landon Phillips
.14,WATER ZONES'::, „- . . II •!.@`:it..; .. . . . . .
Well Contractor Name FROM TO DESCRIPTION
3441A g 2 ft. 3.c ft• 25 ; •
ft. ft. • . I NC Well Contractor Certification Number
15.OUTER CASING(fo'r multi=cased wells)"OR LINER(if ap licable) • •
NW Poole Well and Pump Company FROM TO `DIAMETER I THICKNESS MATERIAL
Company Name •�a f 3 , ft. - (..f Ill. , 2( (. 1Q 1R,
-165INNER CASING OR TUBING(geothermal closed-loop).!'t • •
2.Well Construction Permit#: FROM TO DIAMETER. THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC County,State,Variance,etc.) ft. ft.. I in.' -
3.Well Use(check well use): ft. ft, is " "
Water Supply Well: ,17.SCREEN •'`'. , ,
Oncpal/Public
FROM TODIAMETER .SLOT SIZE THICKNESS MATERIAL •
❑Agricultural ii ft. ft. - in. -
❑Geothennal(Heating/Cooling Supply) ItRt sidential Water Supply(single) ft. ft. in `
❑Industrial/Commercial ❑Residential Water Supply(shared) ' •
CI Irrigation ❑Wells>100,000 GPD FROM TO MATERIAL. EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0 ft. 33) ft.
r`
OMonitoring ❑Recovery ft. ft. n� ,,r—
Injection Well: 4 ft. ft. ..•,,
❑Aquifer Recharge ❑Groundwater Remediation 19.SANDlGRAVEL'PACK(if applicable)
❑Aquifer Storage and Recovery OSalinity Barrier FROM TO MATERIAL EMPLACEMENrMETIIOD
❑Aquifer Test ❑Stormwater Drainage ft. ft•
❑Experimental Technology OSubsidence Control ft. ft. i '
OGeothermal(Closed Loop) OTracer 20.DRILLING.LOG(attach additional sheets if necessary) .
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) FROM TO DESCRIPTION(color,hardness,sail/rock type,grain size,etc.)
U ft' d- ft• v.�' Is �'
4.Date Well(s)Completed: '-T-Z 3 Well ID# n� ft. aQ ,ft. 3aAct _ .
Sa.Well Location: / a.•0 ft. C0OS- ft. Cranti-- R=e %r•¢*R it r°
Li
i4c<et 1 r'rc4 e e, i r/ r/r/� it ft �J 1...t qV
Facility/Owner Name / Facility ID#(if applicable) ft. ft. ! AUG 2 "! /Q73 _ _
0 Ple°aSi,,, F dr+1- , ('.�lu,,,l7 Ref i7- t La, k ft. ft ., .
f ft. ft [ttivrTn, o it ri. y,..si' trrttJ
Physical Address,City,and Zip ,, DVt O C)1
21.REMARKS.. , , '
(_,OtCe Used hardened steel drive shoe.
County Parcel Identification No.(PIN)
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(if well field,{one 1at/longgiissufficient) Q� I r 22.Certifieati
S. bteO /(J N It i•(ILQD7 WJ.,.,,,.da.-11 .ez--- , 1 1.4'q-2/
6.Is(are)the well(s): ❑Permanent or OTemporary Signature of Certified Well Contractor Date
By signing this form,I hereby cert(/that the well(s)was(were)constructed in accordance with
7.Is this a repair to an existing well: ❑Yes or BNo 1SA NCAC 02C.0100 or 1SA NCAC 02C.0200 Well Construction Standards and that a con;'
If this is a repair,fill out known well construction information and explain the nature of the of this record has been provided to the well owner.
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
S.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide'additional well construction info
construction,only I GW-i is needed. Indicate TOTAL NUMBER of wells (add'See Over'in Remarks Box).You may also attach additional pages if necessary.
drilled:I 24.SUBMITTAL INSTRUCTIONS
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9.Total well depth below land surface: l9 Q 5 (ft)
For multiple wells list all depths if different(example-3@200'and 2@100') Submit this GW-1 within 30 days of well completion per the following:
U fk 24a. For All Wells: Original form to Division of Water Resources (DWR), •
10.Static water level below top of casing: ( ) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
If water level is above casing,use"+"
11.Borehole diameter: 6 (in.) 24b.For Injection Wells: Copy to DWR, Underground Injection Control(IUC)
Program,1636 MSC,Raleigh,NC 27699-1636
Rotary r .
12.Well construction method: 24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health departments of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) a c- Method of test: BLOW Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: HTH Amount: 1 lb.
Form GW-I North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018